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Southern Arizona VA Health Care Center Rotation

Educational Purpose

The objective of this rotation is to provide an experience for fellows to provide consultative services on patients admitted to the Southern Arizona VA Health Care Center on whom a consultation has been requested. In addition during the rotation a fellow will screen new out patient Hematology and Medical Oncology Clinic referrals and prioritize them to be seen.

Provide under attending physician supervision a review of all new referrals to the out patient clinics held by the Hematologists and Medical Oncologists at the Southern Arizona VA Health Care Center. If a new referral needs to be seen, a fellow on this rotation will see the patient, perform a history and physical examination, order diagnostic and imaging studies and create a management plan for individuals referred to the out patient clinics..

Perform under attending supervision the following procedures and deductive services:

Bone marrow aspiration and biopsy

Performance of LPs with the administration of chemotherapy

Oral and intravenous ordering and administration of chemotherapy

Management of central venous access devices

Measurement to tumor masses on physical exam and imaging studies

Correlating clinical findings with pathologic information.

Palliation of malignancy related accumulation of fluids within the body.

Performing therapeutic phlebotomies and pheresis

Preparation and interpretation of blood and bone marrow smears

Present findings to attending physicians for critique and feedback.

Communicate under attending supervision with patients and their families medical information, therapeutic recommendations, and prognosis discussions.

Perform medical literature reviews on the diagnoses and conditions of patients seen and review a summary to the review with the attending physician.

Present cases of interest for education purposes to multi-disciplinary conferences.

Mix of Diseases Seen

Patients who have been hospitalized at the Southern Arizona VA Health Care Center or who are seen in the out patient Hematology and Medical Oncology clinics represent individuals who are afflicted with the spectrum of blood and bone marrow disorders together with those individuals who suffer from cancers. Typical patients would include those with anemias, blood counts that are two high or two low, individuals with leukemias or myeloma, individuals with lymphomas, and individuals with lung, colon, breast, genitourinary, sarcomas, etc with resistant cancer. The patients seen represent a broad spectrum and social, cultural and economic circumstances thus providing and excellent teaching experience for trainees to enhance their communication skills.

Types of Clinical Encounters

Patients managed as in-patients and those managed in the out patient clinics at the Southern Arizona VA Health Care Center attending supervision represent the spectrum of individuals cancers, benign hematologic disorders and malignant hematologic disorders. As part of providing this service the experience the fellow gets requires s fellow to perform definitive diagnostic services, assessment of extent of disease and determining all management options, managing cancer and blood disorder disease complications, and managing treatment related complications. In addition to seeing, assessing, and managing patients under attending supervision, fellows will interact and provide didactic support for other health care providers involved in the care the in patients and patients on the consultative services. Fellows also will arrange continuity of care when patients are transitioned into the out-patient setting. Procedures will be done under supervision as deemed necessary for optimal care under attending physician supervision.

Procedures Anticipated

Bone marrow aspiration and biopsy

Performance of LPs with the administration of chemotherapy

Oral and intravenous ordering and administration of chemotherapy

Management of central venous access devices

Measurement to tumor masses on physical exam and imaging studies

Correlating clinical findings with pathologic information.

Palliation of malignancy related accumulation of fluids within the body utilizing removal or injecting of palliative therapies

Performing therapeutic phlebotomies and pheresis

Preparation and interpretation of blood and bone marrow smears

Rotation Specific Competency Based Goals and Objectives

Patient Care

With the completion of each rotation at the Southern Arizona VA Health Care Center, a fellow will gain increasing skill, precision, efficiency and accuracy in performing admitting history, physical exams, assessments and formulations of management plans.

With the completion of each rotation the fellow’s skill in providing written accurate, succinct and sophisticated subspecialty evaluations and management plan formulations will increase.

With the completion of each rotation, the fellow will become increasingly proficient and accurate in formulating differential diagnoses in the subspecialty’s patient population.

Medical Knowledge

With the completion of each rotation the fellow will gain an ever increasing knowledge base about each of the diagnoses seen by Hematologists and Medical Oncologists.

With the completion of each rotation the fellow will gain an increasing knowledge about the risk benefit of each therapy provided to individuals with the diagnoses seen by the Hematology and Medical Oncology Service.

With the completion of each rotation the fellow will gain an increasing knowledge about the spectrum of palliative intervention and their risk benefit issues.

Interpersonal and Communication Skills

With the completion of each rotation the fellow will gain an increased experience and skill in multidisciplinary treatment planning and how to relate and communicate effectively with the team

With the completion of each rotation the fellow will gain an increased experience and skill in supervising and teaching medical trainees and lower levels and in communicating diagnostic conclusions and management recommendations to teams requesting consultative help.

With the completion of each rotation the fellow will gain an increased experience in creating written documentation of historical details, findings of physical exam, results of diagnostic studies, and describing differential diagnoses, conclusions and management recommendations.

With the completion of each rotation, the fellow will gain an increased experience in communication with patients and their families particularly in discussing clinical assessment and management recommendations.

With the completion of each rotation, the fellow will gain an increased experience and skill in providing emotional support to patient and family with an emphasis on compassion and respectful, professional behavior.

Professionalism

With the completion of each rotation, the fellow will gain an increased experience and serving as a resource to the family for clarifying questions and developing a management plan in which each family member and the patient understands their role.

With the completion of each rotation and with attending physician supervision and feedback a fellow will demonstrate respect, honesty, compassion and integrity in all aspects of the relations with the health care team and the patient and their family.

With the completion of each rotation the fellow will gain an increased understanding of the importance of maintaining strict confidentially and ethics.

Practice Based Learning and Improvement

The fellow will engage in self-directed reading/learning on daily patient assessment and management issues.

As it relates to the patients being managed or consulted on by the Bone Marrow Transplantation Service, a fellow with the completion of each rotation will increasingly be able to find and apply information from the medical literature to the diagnostic plan and management plan.

The fellow with the completion of each rotation will increasing become skilled in the utilization of electronic records, on line medical information resources and be able to provide educational materials to patients and their families.

Competency Goals Based on Year of Training

At the end of the first year of fellowship training, a fellow should have obtained a general knowledge of benign and malignant hematologic disorders and of cancers.

Each year the knowledge should increase so by the end of the third year, the knowledge obtained should be adequate to allow a fellow to successful pass the written certification exams.

By the end of the first year fellows should be experienced in the performance and interpretation of bone marrow aspiration and biopsies and be able to perform the procedures without supervision.

By the end of the first year of fellowship, a fellow should be able to complete chemotherapy orders with therapy ordered with the correct dosages, routes of administration and premedications to minimize the risk of treatment related toxicity.

By the end of the 2nd and 3rd year of fellowships a fellow should be able to correct translate a chemotherapy management plan as it relates to an unusual condition or circumstance from the medical literature to the ordering and administration to a specific patient.

By the end of the 3rd year, a fellow should have acquired the knowledge, skills, and communication abilities to function independently as a subspecialist in the fields of Hematology and Medical Oncology in this case specifically the use of bone marrow transplantation.

Reading List

Please reference the ASCO and ASH national recommended reading lists provided in a separate section in this curriculum.

Pathologic Materials

On all patients who undergoing biopsies, especially bone marrow aspirations and biopsies, a fellow is expected to review the pathologic materials microscopically with the pathology team be it histologies or cytologies.

Educational Resources

Computerized internet access to the Medical Library at the University of Arizona College of Medicine is available to all trainees both within the facility and at home. In addition the library itself is open 24 hours per day 7 days per week and has an excellent collection of books and journals relating the Hematology and Medical Oncology. In addition the library provides on line internet access to the National Library of Medicine and other subscription medical information services such as “Up to Date” at no charge to trainees.

Competency Emphasis During Rotation (Low, Intermediate or High Emphasis)

Patient Care

High

Medical Knowledge

High

Practice Based Learning and Improvements

High

Interpersonal and Communication Skills

High

Professionalism

High

System Based Practice

High

Evaluation Process Tools (Used, Yes or No)

Attending Written Evaluation

Yes

360 degree coworker evaluation

Yes

Cognitive Testing/In Service Exam

Yes

Focused Observation (Mini CEX)

No

Certification Examination

No

Procedures

Yes

Morbidity and Mortality Presentations

Yes

Level of Fellow Supervision

Fellows are supervised directly by Hematology and Medical Oncology attending physicians. Depending on the situation, this may be direct visual supervision as occurs during procedures and staffing a consultation or it may be verbal supervision of the telephone as occurs when discussing lab results, management plans and after hours consultation. As the fellows knowledge, skills and experience improve, they will be take and ever increasing role in the diagnosis, formulation of management plans, and communication with patients and family so that by the end of the fellowship they are able to function independently. However, throughout all three years of the fellowship, an attending physician is always present and supervision and providing education and critique of a fellow’s performance.